Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are repeated at the end of the Major Recommendations.
Does a B-type natriuretic polypeptide (BNP) or N-terminal (NT)-ProBNP measurement improve the diagnostic accuracy over standard clinical judgment in the assessment of possible acute heart failure syndromes in the emergency department (ED)?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. The addition of a single BNP or NT-proBNP measurement can improve the diagnostic accuracy compared to standard clinical judgment alone in the diagnosis of acute heart failure syndrome among patients presenting to the emergency department (ED) with acute dyspnea.
Use the following guidelines:
- BNP <100 pg/dL or NT-proBNP <300 pg/dL acute heart failure syndrome unlikely* (Approximate negative likelihood ratio [LR-] = 0.1)
- BNP >500 pg/dL or NT-proBNP >1,000 pg/dL acute heart failure syndrome likely (Approximate positive likelihood ratio [LR+] =6)
Level C recommendations. None specified.
*BNP conversion: 100 pg/mL=22 pmol/L; NT-proBNP conversion: 300 pg/mL=35 pmol/L
Is there a role for noninvasive positive-pressure ventilatory support in the ED management of patients with acute heart failure syndromes and respiratory distress?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. Use 5 to 10 mm Hg continuous positive airway pressure (CPAP) by nasal or face mask as therapy for dyspneic patients with acute heart failure syndrome without hypotension or the need for emergent intubation to improve heart rate, respiratory rate, blood pressure, and reduce the need for intubation, and possibly reduce inhospital mortality.
Level C recommendations. Consider using bi-level positive airway pressure (BiPAP) as an alternative to CPAP for dyspneic patients with acute heart failure syndrome; however, data about the possible association between BiPAP and myocardial infarction remain unclear.
Should vasodilator therapy (e.g., nitrates, nesiritide, and angiotensin-converting enzyme [ACE] inhibitors) be prescribed in the ED management of patients with acute heart failure syndromes?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. Administer intravenous nitrate therapy to patients with acute heart failure syndromes and associated dyspnea.
Level C recommendations.
- Because of the lack of clear superiority of nesiritide over nitrates in acute heart failure syndrome and the current uncertainty regarding its safety, nesiritide generally should not be considered first line therapy for acute heart failure syndromes.
- ACE inhibitors may be used in the initial management of acute heart failure syndromes, although patients must be monitored for first dose hypotension.
Should diuretic therapy be prescribed in the ED management of patients with acute heart failure syndromes?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. Treat patients with moderate-to-severe pulmonary edema resulting from acute heart failure with furosemide in combination with nitrate therapy.
Level C recommendations.
- Aggressive diuretic monotherapy is unlikely to prevent the need for endotracheal intubation compared with aggressive nitrate monotherapy.
- Diuretics should be administered judiciously, given the potential association between diuretics, worsening renal function, and the known association between worsening renal function at index hospitalization and long-term mortality.
Definitions:
Strength of Evidence
Literature Classification Schema^
Design/
Class |
Therapy* |
Diagnosis ** |
Prognosis*** |
| 1 |
Randomized, controlled trial or meta-analyses of randomized trials |
Prospective cohort using a criterion standard |
Population prospective cohort |
| 2 |
Nonrandomized trial |
Retrospective observational |
Retrospective cohort
Case control
|
| 3 |
Case series
Case report
Other (e.g., consensus, review)
|
Case series
Case report
Other (e.g., consensus, review)
|
Case series
Case report
Other (e.g., consensus, review)
|
^ Some designs (e.g., surveys) will not fit this schema and should be assessed individually.
*Objective is to measure therapeutic efficacy comparing >2 interventions.
**Objective is to determine the sensitivity and specificity of diagnostic tests.
*** Objective is to predict outcome including mortality and morbidity.
Approach to Downgrading Strength of Evidence*
| |
Design/Class |
| Downgrading |
1 |
2 |
3 |
| None |
I |
II |
III |
| 1 level |
II |
III |
X |
| 2 levels |
III |
X |
X |
| Fatally flawed |
X |
X |
X |
*See "Description of Methods Used to Analyze the Evidence" field for more information.
Strength of Recommendations
Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues)
Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies)
Level C recommendations. Other strategies for patient management that are based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.
